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ACA (Affordable Care Act) plans sold on the Health Insurance Marketplace (healthcare.gov or state exchanges) must cover the 10 essential health benefits, cannot deny coverage based on pre-existing conditions, and cannot charge women more than men. Open enrollment runs from November 1 through January 15 (dates may vary). Special enrollment periods are available after qualifying life events like job loss, marriage, or having a baby.

Plans are categorized by actuarial value (AV) — the percentage of average costs the plan pays. Bronze (60% AV) has the lowest premiums but highest out-of-pocket costs. Silver (70% AV) is the middle tier and the benchmark for subsidy calculations. Gold (80% AV) has higher premiums but lower out-of-pocket costs. Platinum (90% AV) has the highest premiums but lowest out-of-pocket costs. If you qualify for Cost-Sharing Reductions (income below 250% FPL), you must enroll in a Silver plan to receive them.

The Premium Tax Credit (PTC) is a subsidy that reduces your monthly premium. The credit is calculated as the difference between the benchmark Silver plan premium in your area and the maximum amount you're required to contribute based on your income relative to the Federal Poverty Level (FPL). If you earn between 100% and 400% FPL, you are generally eligible. The American Rescue Plan Act (through 2025) also caps contributions at 8.5% of income for households above 400% FPL.

The Federal Poverty Level (FPL) is a measure of income used to determine eligibility for federal programs. For 2024, the FPL for a single person in the contiguous U.S. is $14,580. Your eligibility for Medicaid, subsidies, and cost-sharing reductions depends on your income as a percentage of FPL. Between 100–400% FPL you qualify for subsidies; below 138% FPL (in states that expanded Medicaid) you may qualify for Medicaid instead.

MAGI for ACA purposes is your adjusted gross income (from your tax return) plus any tax-exempt interest, non-taxable Social Security benefits, and excluded foreign income. It's generally close to your gross income if you have standard W-2 employment. The ACA uses projected MAGI for the coverage year — if your actual income differs significantly from your estimate, you may owe back subsidies or receive a refund when you file taxes.

If your employer offers coverage that is considered affordable (employee-only premium ≤ 9.02% of household income in 2024) and meets minimum value requirements, you are generally not eligible for marketplace subsidies. However, if your employer coverage is not affordable or doesn't meet minimum value, you may qualify for subsidies on the marketplace even if employer coverage is available.

The deductible is the amount you pay before your insurance starts covering most services. The out-of-pocket maximum (OOP max) is the most you will pay in a year — after hitting this limit, insurance covers 100% of covered costs. A copay is a fixed amount you pay for specific services (e.g., $30 per primary care visit). Bronze plans typically have high deductibles ($6,000–$8,000) and lower premiums. Platinum plans have low deductibles and higher premiums.

Outside of the annual Open Enrollment Period (November 1 – January 15), you can only enroll in or change marketplace plans if you experience a qualifying life event. These include: losing other health coverage (e.g., job loss, aging off a parent's plan at 26), getting married or divorced, having or adopting a child, moving to a new coverage area, and certain income changes. You typically have 60 days from the qualifying event to enroll.